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    Danial McCrae

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    Si Thi
    Mr. Daniel McCrae is a 51-year-old male patient who presented with symptoms of fatigue, abdominal discomfort, and changes in bowel habits. Tests revealed positive fecal occult blood and an adenocarcinoma in the ascending colon on colonoscopy. I am referring Mr. McCrae to you for surgical assessment and further management of his diagnosed adenocarcinoma of the ascending colon.

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    Danial McCrae

    Uploaded by

    Si Thi
    57 views3 pages
    Mr. Daniel McCrae is a 51-year-old male patient who presented with symptoms of fatigue, abdominal discomfort, and changes in bowel habits. Tests revealed positive fecal occult blood and an adenocarcinoma in the ascending colon on colonoscopy. I am referring Mr. McCrae to you for surgical assessment and further management of his diagnosed adenocarcinoma of the ascending colon.

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    Mr. Daniel McCrae is a 51-year-old male patient who presented with symptoms of fatigue, abdominal discomfort, and changes in bowel habits. Tests revealed positive fecal occult blood and an adenocarcinoma in the ascending colon on colonoscopy. I am referring Mr. McCrae to you for surgical assessment and further management of his diagnosed adenocarcinoma of the ascending colon.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    57 views3 pages

    Danial McCrae

    Uploaded by

    Si Thi
    Mr. Daniel McCrae is a 51-year-old male patient who presented with symptoms of fatigue, abdominal discomfort, and changes in bowel habits. Tests revealed positive fecal occult blood and an adenocarcinoma in the ascending colon on colonoscopy. I am referring Mr. McCrae to you for surgical assessment and further management of his diagnosed adenocarcinoma of the ascending colon.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    Daniel McCrae

    Read the case notes below and complete the writing task which follows.

    Notes: Mr Daniel McCrae is a patient in your general practice.

    History:

    DOB: 17 October 1962 , Height: 180cm , Weight: 91kg , BMI: 28.1

    Social background:

    • Smoker

    • Married, 4 children (23, 20, 10, 8 yrs)


    • Barrister

    • Hobbies: Reading, cooking, art, music

    19/09/13:

    • Pt fever, sore throat, cough, headache, body aching

    • wants antibiotics so no need for time off work - v busy

    O/E:

    • BP - 120/75

    • Heart rate - 76 bpm

    • Chest - clear
    • Wt - 91kg
    • BMI - 28.1

    • Temp - 38.9°C

    Tests: None

    Assessment: Viral infection

    Plan:

    • Rest 1-3 days until fever subsides, symptoms weaken

    • Paracetamol

    • R/V if symptoms persist > 5 days


    08/02/14

    • Pt feeling tired. ‘Off-colour' as if never fully recovered from infection (Sep 2013).
    • Complains of unsettled system for several weeks - abdominal discomfort, gas,

    diarrhoea/constipation; feels fatigued.

    • Still under some stress from workload.

    • No family history of colorectal carcinoma, colonic polyps or inflammatory bowel


    disease.

    O/E:

    • BP - 115/80

    • Heart rate - 77bpm


    • Wt - 92kg

    • BMI - 28.4
    • Temp - 31.1°C

    • Abdomen soft, lax, no masses, no guarding or rebound

    • Normal bowel sounds

    Assessment:

    • ? Irritable bowel syndrome

    • ? Crohn's disease, ulcerative colitis, inflammatory bowel disease


    • ? Unfit, Overweight

    Plan:

    • Investigations: CBC , Faecal occult blood test (FOBT), Colonoscopy

    • R/V in 2 weeks for test results


    22/02/14: Pt still feeling unwell

    O/E:

    • BP - 120/85,

    • Heart rate - 74bpm

    • Chest - clear , Temp - 37°C


    • No abdominal mass

    Results:

    • CBC: normal, WBC (8.5) , ↓ Hb (91), ↑ Hct (34%) , FOBT: positive

    • Colonoscopy: abnormal. Malignancy detected in ascending colon; biopsy taken and


    adenocarcinoma diagnosed

    Assessment: Adenocarcinoma of the ascending colon

    Plan: Refer to colorectal surgeon for assessment ASAP

    Writing Task:

    Using the information given in the case notes. write a letter of referral to: Associate

    Professor Anderson, Surgeon, Suite 65. City Hospital. 25-29 Main Road. Centreville.

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